New Patient Registration Forms

To save you time on the day of your first appointment, please print the forms below, complete them, and bring them with you to your consultation. Thank you.

Medical Release Authorization

Please fill complete the form below to authorize release of your child's medical information. Medical records sent to another provider for continuity of care do not have associated fees. This form must be complete, including the date and signature as we cannot process incomplete forms.  Medical Record reproduction fees for personal use are listed below:

  • $18.97 for base fee

  • $0.63 per page

  • $20.00 for CD of radiographs

Authorization Form for Release of Medical Records

Please sign, date, & fax this form to (913) 491-0547, or submit to our office by hand, by mail, or by scanning & emailing to businessoffice@pedorthokc.com.